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The Nautical Institute Marine Accident Reporting SchemeMARS Report No 201 July 2009

MARS 200935 Eye injury due to burst hoseShortly after our tanker arrived at the designated berth, thebosun was operating the hose-handling crane to position thevessel’s gangway to provide safe access to the ship. Duringthis operation, a flexible hose on the crane came adrift fromits coupling and hydraulic oil under high pressure sprayedout, some of it entering the bosun’s eyes. About 200 litres ofspilled hydraulic oil had to be collected from the deck anddisposed of appropriately.

Root cause/contributory factors1. Inappropriate use of anticorrosive tape, whichdeteriorated with time and aided the development ofundetected corrosion;

2. Routine inspections were carried out without sufficientattention to detail and failed to detect the deterioratedcondition of the hose and connector;

3. The quantity of oil spilled on deck was abnormally large,as the crane was not fitted with an emergency stop for thehydraulic power pack. This could only be turned off locallyfrom the fo’c’sle, a considerable distance away.

What went right1. The crew acted quickly to provide first aid to the injuredcrew member;

2. The spilled oil was prevented from escaping overside.

Corrective/preventative actions1. Company procedures revised and circulated among fleetfor compliance; the use of anticorrosive tapes no longerpermitted on hydraulic lines, as detailed in our company’smaintenance policy. All vessels were instructed to remove allexisting anti-corrosive tape from hydraulic connectors andapply protective coating (paint) on metal surfaces.

2. More effective onboard inspection and corrective actionsordered for noted defects and deficiencies.

3. Improved communications so that information reaches allkey personnel.

4. Recommendation that the use of eye protection should beconsidered when operating hose handling cranes or otherhydraulic machinery where flexible hoses and fittings may beexposed to the aggressive elements of the sea.

5. Recommendation that the flexible hoses on the hosehandling crane be renewed every five years or earlier, ifinspection indicates it is so required.

MARS 200936 Lifeboat lowered unintentionally

On one of our vessels, a dangerous occurrence (near missincident) happened during the annual servicing and inspectionof the lifeboat and its launching gear in port.

The class surveyor and the authorised representative ofthe launching equipment manufacturer were in attendanceduring the survey, with the technical superintendent. After thesurvey was completed, the manufacturer’s representativeinformally asked the fourth engineer to open up the port sideunit brake assembly the next day so that he could takepictures for his records.

Early the next morning, the fourth engineer, along with thebosun, wrongly assumed that the job was officially assigned tothem and proceeded to open up the brake unit on the portlifeboat davit. On opening the cover bolts, the boat went downrapidly under gravity until it got stuck between the gangwayand the jetty. Fortunately, there was no one inside the boat oron the gangway in way of the davits. The superintendent, whowas on the jetty inspecting the ship side at that time, had anarrow escape.

� Figure 2: Corroded internal wire braiding after removal of protective tapeand connector

� Figure 1: Deteriorated connector partly covered with protective tape

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2. Inadequate supervision of the operation by a senior orother officer;

3. Insufficient personnel assigned for all the activities thatwere taking place;

4. Failure to temporarily suspend work inside the enclosedspace during PSC inspection or until satisfactory manninglevels could be assured;

5. Lack of appreciation of the importance of the stand-bywatchman / linkman for monitoring personnel engaged inwork inside an enclosed space.

What went rightFollowing the incident, all involved contributed openly to theinvestigation, allowing the investigation team to review theincident with clarity and arrive at appropriaterecommendations.

Lessons learned1. The appointment of a permanent stand-by watchman orlink man at the entrance of the enclosed space should beclearly discussed by the supervising officer at the pre-entryconference, with emphasis on ensuring that he would not bedistracted by, or engaged in, other activities during theenclosed space entry.

2. Risk assessments conducted for port calls should take intoaccount the likelihood of unannounced or a demanding ofvisitors to the ship and ensure that adequate procedures(controls) are put in place to ensure sufficient numbers ofstaff are on duty at all time to cover statutory requirements.

3. Ensure all persons engaged in enclosed space entryprocedures, and particularly those acting as link man, havebeen informed of their duties and understand them.

� Editor’s note: The report does not state if the ABmanning the gangway was, in turn, properly relieved byanother crew member. Although one can reasonablypresume that the slop tank manholes were probablylocated in the immediate vicinity of the gangway, and thatthe AB could have supervised the personnel working insidethe tank during the OS’s short break, while also watchingthe gangway, under the ISPS Code those personnelassigned gangway security duty may not be assigned anyother task.

MARS 200938 Dragging of anchor and collisionOur vessel was anchored in a crowded inner anchorage with acurrent of up to two knots. A squall was observed approachingfrom the opposite direction of the tide. Own vessel contactedengine room to request engine and thrusters. As the squallpassed, own vessel started to drag anchor. Fortunately theengine was started and vessel put into DP mode andsuccessfully maintained position.

Among the other vessels in close proximity, a cargo vesselwas observed to be dragging towards a tanker. Within 10minutes, the two vessels had collided. During this period,nobody was observed on the bridge or the deck of the cargovessel: only upon impact did crew members appear. On boardthe tanker the OOW had observed what was happening,however the engine was started late. But there was no

Root cause/contributory factors1. Breach of safe working practices: a critical task wasundertaken without the knowledge or approval of responsiblesenior ship’s officer / head of department;

2. The harbour pins were not in place;

3. The two crew members involved were not sufficientlyexperienced in the task.

Corrective/preventive actions1. Incident report circulated throughout the company andfleet.

2. Company procedures amended to require that all criticaltasks be planned and supervised by senior officers. No oneshould enter the life boats or carry out any maintenance workon lifeboats and associated launching appliances withoutclear instructions and the presence of a senior officer. Seniorofficers assigning jobs must take full responsibility for all jobsthat are being carried out by their subordinates.

MARS 200937 Breach of enclosed space entryprocedureWhile our tanker was moored alongside a lay-by berth forminor repairs, the attending port state control (PSC) officersobserved work being carried out in an enclosed space (sloptank) without a nominated person standing by at the entrance.This observed unsafe practice constituted a major non-conformance with the company’s SMS procedures, permit towork system and industry best practice. As a result, PSCrecorded a deficiency, requiring the company to conduct aformal investigation into enclosed space entry procedures andinform the outcome to all vessels.

Result of investigation1. Repairs were being carried out to hydraulic lines in theslop tanks. Initially, six separate activities were planned forthe short port call but after conducting a risk assessment, twoactivities were cancelled to ensure adequate supervision couldbe maintained. Accordingly, a company superintendent wasdispatched to the ship to assist.

2. In the permit to work, the second officer was assigned aswatchman and supervisor for the enclosed space entry andrepair job. During this time, the PSC inspection was also inprogress. When the second officer was requested to attend thenavigation bridge, he was relieved by an OS. Shortly after, theOS was relieved for a break by the duty AB, whose dutiesincluded the gangway security watch.

3. Some 15 minutes later, visitors appeared at the gangwayhead and this required the attendance of the duty AB, tocomply with ISPS security procedures. While he processed thenewly arrived visitors, the chief officer, accompanied by thePSC inspectors, arrived on deck and observed the work beingconducted in the enclosed space without an attendingwatchman / linkman monitoring the safety of the occupants.

Root cause/contributory factors1. Lack of planning and failure to inform PSC that the secondofficer was supervising work in progress inside the enclosedspace, when his presence was requested on the bridge;

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pollution and no report was made to the port authority overthe radio.

Lessons learned1. An efficient lookout and watch must be maintained at alltimes at anchor.

2. Beware of dragging, especially when in an area of strongtides / current.

3. Have engines on short notice when in crowded anchorage.

4. Have contingency plans in place, especially in areas wheresqualls can be expected.

5. Report incidents to the port authorities promptly.

MARS 200939 Poor housekeeping in machineryspaces

� Figure 3: Improvised plastic ‘drip tray’ fitted under sludge pump

� Figure 4: Receptacles placed under leaking hydraulic cylinders of steeringgear

MARS 200940 Fire in provision roomOfficial report: IMO Flag State Implementation (FSI) Sub-committee, 12th session

A fire broke out in the provision room of a small general cargoship which had a complement of only five. The crew wereunable to contain it and it spread to the accommodation,forcing the master to abandon the ship with all crew. Theywere all rescued by helicopter.

Root cause/contributory factorsThe root cause is not stated in the report, however thefollowing contributory factors are noted: Editor

1. There was only one self-contained breathing apparatus(SCBA) set onboard, which inhibited the capability of the crewin fighting the fire;

2. A CO2 extinguisher was used to knock down the fire;however, it re-ignited as the space was not effectively sealed;

3. The spread of the fire to the accommodation could not becontrolled because the crew failed to follow boundary-coolingtechniques and monitor all sides of the provision room;

4. Further, the senior officers had failed to take control ofthe fire party, to assess the situation and consider using adifferent medium to fight it.

Lessons learned1. CO2 can knock down a fire quickly: however its coolingeffect is limited.

2. To prevent re-ignition, the space containing the seat of fireshould be effectively sealed.

3. When applying boundary cooling to contain a fire, all sidesof the space should be monitored.

4. Smoke helmets are not as effective as SCBAs for fire-fighting, especially on vessels with only a small number ofcrew. The IMO Maritime Safety Committee (MSC) has issued acircular highlighting the problems associated with the use ofsmoke helmet-type of breathing apparatus (MSC/Circ.1085).

5. The fire party should be led by a more senior officer, whoshould use his experience and knowledge to assess the situationand consider the most appropriate means to fight the fire.

6. Shipowners and administrations should consider fightingfires and other emergency situations when determining thesafe manning levels of vessels.

MARS 200941 Galley fireJust before noon, the cook was making French fries in a deepaluminium cooking pan, placed over the hot plate. When thepotatoes were added to the hot oil, the pan was overfilled andsome oil overflowed and landed on to the hot plate. Thetemperature of this was sufficient to cause the oil to auto-ignite. The flames immediately spread, causing the oil vapourin the pan also to ignite.

The cook instantly drew out the fire blanket from itscontainer in the galley and covered the pan with it. However,the spilled oil on the hot plate continued to burn around the

� Editor’s note: These photographs seem to suggest ageneral lack of concern on the part of the onboardmanagement to investigate and eliminate sources of oilleaks from machinery properly. Apart from the obvious firehazard, these arrangements increase the risk of personalinjuries arising from slips and falls. They also present apollution hazard.

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MARS: You can make a difference!Can you save a life, prevent injury, or contribute to a more effective shipping community?Everyone makes mistakes or has near misses but by contributing reports about these events toMARS, you can help others learn from your experiences. Reports concerning navigation, cargo,engineering, ISM management, mooring, leadership, ship design, training or any other aspect ofoperations are always welcome.

MARS is strictly confidential and can help so many – please contribute.

Editor: Captain Shridhar Nivas MNIEmail: mars@nautinst.org or MARS, c/o The Nautical Institute, 202 Lambeth Road, London SE1 7LQ, UKThe Nautical Institute gratefully acknowledges sponsorship provided by:

American Bureau of Shipping, Britannia P&I Club, Cargill, Class NK, Gard, International Institute of Marine Surveying, Lairdside Maritime Centre, Lloyd’s Register-Fairplay Safety at SeaInternational, Marine Design Cenre, Noble Denton, North of England P&I Club, Port of Tyne, Sail Training International, Shipowners Club, The Marine Society and Sea Cadets, The Swedish Club, UK Hydrographic Office, UK P&I Club

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covered pan, so he removed it, still-covered, and doused theflames on the hot plate with a wet towel. He telephoned thebridge to alert the OOW of the situation, by which time the firehad been extinguished with no damage to the galley or injuryto personnel.

Root cause/contributory factors1. Lack of company standard: the vessel was not fitted with astand-alone deep fat fryer, resulting in the unsafe practice ofopen deep frying over a hot plate;

2. There was too much oil in the cooking pan before potatochips were added.

What went right1. Galley staff commended for prompt and effective action.

What went wrong1. No alarm was raised and crew was not mustered in anorganised manner.

Corrective/preventative actions1. Management to consider fitting stand-alone deep fat fryersin all newbuildings.

2. Cooks to use deeper cooking pans and smaller quantitiesof oil when cooking potato chips.

3. Fleet to discuss the incident at safety meeting anddetermine the circumstances under which the fire alarmshould be activated and fire party mobilised. Also to impressupon crews that the fire party should be standing by for sometime after the fire is extinguished to prevent re-ignition. � Figure 6: Cook demonstrating use of fire blanket

� Figure 5: Cook displaying fire blanket after the incident